Addressing alcohol use in general practice - a community-oriented approach

Background Even though often socially accepted, alcohol is one of the leading risk factors for poor health and death in the world. Therefore, the world health organization (WHO) promotes the integration of alcohol-related early identification and brief intervention (EIBI) in general practice as one of the most cost-effective strategies to address this burden. However, implementation of EIBI in general practice remains low. Community-oriented strategies (COS), defined as public health activities directed to the general population, are suggested to address this implementation-gap. COS aim to increase the understanding, engagement, and empowerment within the population to facilitate EIBI delivery. COS are believed to be essential for facilitating alcohol related EIBI implementation in general practice, but there remains uncertainty on how these COS should look like, how they should be implemented, how they should be evaluated and what their potential added value are. This thesis aimed to investigate these evidence gaps, addressing the pressing issue of hazardous and harmful alcohol use in society. Methods This thesis was structured in a stepped, evidence-based approach. First, the existing literature was mapped using a scoping review to explore what is known and to define key elements of COS to facilitate EIBI delivery in general practice (chapter 2). Second, the views, ideas and priorities of all relevant stakeholders were explored using the nominal group technique generating a list of COS (chapter 3). Third, we gathered all available knowledge to design a strategy for improving EIBI delivery in general practice and evaluate the potential added value of COS (chapter 4). Fourth, the effects of COS were evaluated in both general practice and the community itself. This by means of a repeated cross-sectional study to monitor the impact on the community (chapter 5). Additionally, a quasi-experimental trial was set up to evaluate the developments of EIBI delivery in general practice and the implementation of a structured EIBI registration in GP's EHR systems (chapter 6). In the final chapter, we explored a new way of measuring the potential impact of alcohol-related interventions on the community. The use of wastewater-based epidemiology (WBE) for monitoring a community was evaluated in a case study linking alcohol consumption with the COVID-19 regulatory measures (chapter 7). Results In chapter 2, the scoping review, we highlighted the lack of empirical evidence to support the added value of COS to facilitate EIBI delivery. Most available literature presents a concept or idea but does not include a thorough evaluation of the effect of COS. They mainly focus on mass media campaigns, communitywide self-assessment and waiting room actions to inform the population regarding the effects of alcohol use and prompt people to discuss alcohol use with their GP. The presented ideas do however have a theoretical ability to change behaviour and thus facilitate EIBI delivery in general practice. In chapter 3, our findings from the NGT study resulted in a stakeholder inspired 9-item list with COS. The highest ranked COS comprises an awareness campaign directed to the general population highlighting the pro-active role of the GP concerning alcohol use, alcohol-related questions, and health promotion. Further, stakeholders stress the need for combining such an awareness campaign with local neighbourhood mediated actions. This to start the conversation on alcohol use outside the clinical setting and create a more favourable situation in general practice to eventually discuss alcohol use. Chapter 4 and 5 present and evaluates a strategy to implement COS to improve EIBI delivery in general practice. The findings gathered from the quasi-experimental trial indicate no additional effect of COS on the delivery of EIBI in general practice. There was however the interference by the global COVID-19 pandemic, which could have affected daily practice of the participating GPs. Further, in chapter 6, Our findings showed that in general men are more prone of showing positive attitudes towards hazardous or harmful alcohol drinking behaviours than women. No statistically significant changes were recorded over time regarding alcohol-related attitudes like abstinence, getting drunk or heavy episodic drinking. The knowledge on the AWI showed no significant improvement over time. In addition, the findings from the survey study did show that the population aged 55 years and older are more prone to direct their alcohol related questions to the GP when compared to the youth where the internet remains the first choice for answers. Our findings remain inconclusive on the effects over time of the potential effect of COS on EIBI delivery. The final chapter (chapter 7) presented the use of WBE to monitor alcohol consumption within a community. Our data showed that WBE is sensitive and effective for monitoring changes in a community. Conclusion This thesis added to the existing literature by providing a better understanding on the design of COS that aim to facilitate EIBI delivery in general practice. The added value of COS on EIBI delivery remains inconclusive due to interference by the COVID-19 pandemic. The findings and experiences of implementing and evaluating COS could provide a new precedent for future research endeavours to build upon. First, COS that combine a mass media campaign to create awareness together with local mediated actions to start the conversation outside the clinical setting is our suggestion to facilitate EIBI delivery. Second, there is a need for optimising the EHR system, facilitating daily practice of GPs and providing a possible the evaluation of complementary research. Wastewater-based epidemiology provides a potential new, objective, and accurate means of monitoring a community's alcohol consumption during an intervention.

Publication year:2023

Accessibility:Open